Programme to change inhaler prescribing patterns[1]

Centre for Sustainable Healthcare 2013

Briefing Note, last revised: 03/04/2013

Unintended consequences of respiratory care

The continued use of metered-dose inhalers in respiratory care will have a potentially catastrophic effect on global warming if production is not controlled[2], largely because these inhalersuse potent green-house gas hydroflourocarbons (HFCs) as propellants. A cost-effective and safe alternative is available in the form of Dry Powder Inhalers (DPIs), and we call for clinicians and patients to prescribe and request Dry Powder Inhalers in preference to inhalers using hydroflourocarbon propellants unless clinically contra-indicated.

Background

The World Health Organisation (WHO) estimates that hundreds of millions of people suffer from chronic respiratory diseases[3]. These diseases cannot be cured, but can be controlled using drugs, many ofwhich are delivered by inhalers. The “press-and-breathe” metered dose inhaler (MDI) was introduced in 1956 and is generally credited as being the first inhaler. In this device the drug is dissolved or suspended in a propellant under pressure. When activated, a valve system releases a metered volume of drug and propellant.

The original MDIs contained chlorofluorocarbons (CFCs) as a propellant. With the implementation of the 1987 Montreal Protocol[4]on ozone depletion, the pharmaceutical companies worked in good faith to produce two CFC alternatives: MDI inhaler devices using hydrofluorocarbons (HFCs) as a propellant, and Dry Powder Inhalers (DPIs) that did not require a propellant.

Although not ozone depletion gases, the HFCs developed to replace CFCs (used in refrigeration, air conditioning and MDIs) arepowerful greenhousegases that contribute to global warming. As the main alternative to CFCs, HFC productionis increasing rapidly (from 300 000 tonnes/yearcurrently to a projected 900 000 tonnes/year by 2018).

Alternatives to HFCs, such asammonia and carbon dioxide, are now available for air conditioning and refrigeration, but are not suitable for MDIs. Current HFC use in MDIs isabout 9000 tonnes (about 3% of total use).

This is criticalbecause the implementation of the proposed HFC controls overthe next 40 years could save the equivalent of 70–90 gigatonnesof carbon dioxide, comparable to burning all of the world’s oil.

At current levels 3% or the equivalent of 2.1 to 2.7 gigatonnes of CO2 would be due to MDI inhaler use, and this doesn’t include the increase in prevalence of asthma and COPD.

Clinican& Patient FAQs

  • Are DPIs are as effective as MDIs? Yes, systematic reviews have found no evidence of differences in effectiveness.
  • Are DPIs preferred by patients? Yes, several randomised trials have found that DPIs are preferred and compliance is increased[5].
  • Can DPIs be used by the sickest patients and the very young? No, the very young and very ill cannot use DPIs. DEFRA estimated that 25% will continue to use MDIs.
  • Are DPIs more expensive than MDIs?A tentative “No”. A recent systematic review in the UK[6] and several clinical trials[7] suggest DPIs may be on par or less expensive when associated healthcare costs are taken into account. An analysis in 2012 by a London PCT cluster (population = 600,000) found that direct costs of a 100% switch from MDI to DPI inhalers would be between £38,857 and £600,000, depending on whether the switch was to the most expensive or cheapest powder. In the context of the overall budget of £65m (of which inhalers account for £5.6m), this represents at worst a 1% increase in costs and more likely nearer a 0.1% increase; savings from associated healthcare costs / improved air quality were not quantified.

How to effect change?

Unique to health services is that clinicians decide what to prescribe and therefore are in control. Patients come next – or are on par if they are knowledgeable and confident. Together front line physicians and patients have the power to alter prescribing patterns to reduce harm.

Individual prescribing decisions take place in a context of personal experience and perceptions, local pharmacy arrangements, clinical guidelines and financial constraints. Each of these may need to be targeted for change in order for a large-scale shift away from harmful MDIs.

Next Steps

For the majority of inhaler users a safe and effective alternative to MDIs is already available. We believe what is needed is a programme to change perceptions of clinical efficacy, user acceptability and usage, cost-benefit and ultimately prescribing behaviour. To this end we propose to convene a Programme Board of interested parties – from respiratory specialists to patient groups, GPs to environmentalists and pharmacists to health economists - in Spring 2013. The purpose of the Board is to agree an overall strategy and provide an organisational structure for managing the programme. As part of a Development Phase of the programme we will convene a forum of funders and agree targets, a timeframe and budget.

[1]Contact Details: Rachel Stancliffe, Director, THE CENTRE FOR SUSTAINABLE HEALTHCARE
t: +44 (0)1865 515811
e:

[2]Woodcock A (2012) Prevention is best: lessons from protecting

the ozone layer.

[3]WHO ref:

[4]TheMontreal Protocol on Substances that Deplete the Ozone Layer, last accessed Sept 4th 2012

[5]Welch et al. Comparison of patient preference and ease of teaching inhaler iechnique for Pulmicort Turbuhaler®versus Pressurized Metered-Dose Inhalers. Journal of Aerosol Medicine. June 2004, 17(2): 129-139. doi:10.1089/0894268041457174.

[6]Kemp L, Haughney J, Barnes N, Sims E, von Ziegenweidt J, Hillyer EV, Lee AJ, Chisholm A, Price D. Cost‐effectiveness analysis of corticosteroid inhaler devices in primary care asthma management: a real world observational study.ClinicoEconomics and Outcomes Research.2010;2(1):75‐85;

[7]Liljas B,Stådhl E,Pauwels RA.Cost-effectiveness analysis of a dry powder inhaler (Turbuhaler) versus a pressurised metered dose inhaler in patients with asthma.Pharmacoeconomics.1997 Aug;12(2 Pt 2):267-77.